Telemedicine an distans care in Västerbotten

E-health business models for chronic conditions

Thomas Molén, Strategist

Strategic Development Office

County Council of Västerbotten, Sweden

thomas.molen@vll.se

Northern care region in Sweden (SE)...

• ... occupies 10 % of the population

• ... located on half the Swedish area (total area 449 964 km²)

• Sweden is the 5:th biggest country in Europe

• 9,5 milion citiziens

Distribution of the Swedish population?

• Sweden is sparcely populated in a European perspective: 22 inh/km2

• Västerbotten:

• - 4.7 inh/km2

• - 260.000 inh

Västerbotten county

An important infrastructure component: One

of the fastest networks in the world - owned by public sector

1000 Mbit/sek

Objectives from the National Government

1) By the year of 2020, 90% of all households and companies in Sweden will have access to broadband at a minimum capacity of 100 Mbit/s.

2) Already 2015, 40% should have access to that capacity

Telemedicine - Västerbotten

• Long distances between hospitals and primary

care centers

• Ensure good access to healthcare for the inhabitants

• Reduce travel, work more efficiently, saving the environment, reducing costs

• Projects started back in 1995 – 18 years of experience of telemedicine

Telemedicine - Västerbotten

Status 2013

• All hospitals and primary care centers have

videoconference systems (H.323)

– 180 systems, 800 web camera users

• Very good infrastructure

– Network, video

• Increased use of videoconferencing for administrative use

• Many clinical telemedicine applications

Videoconference - Västerbotten

Sjunet

Internet

Phone/ISDN

H.323 2008 - 2012355 4

82

682 8

27

719

411

66

302

1060

1172

1095

781

818 900

818

791 878 945

99

524

1244

1228 1357

913

1112

1376

1456

1317

1249

979

116

602

1364

1605 1

807

1275

1358

1723 1

897

1496

1957

1118

136

900

1940

1970

2226

1457

19

04

22

90

21

51

15

51

19

74

97

2

13

8

37

2

20

68

23

40

21

86

0

500

1000

1500

2000

2500

jan feb mar apr maj jun jul aug sep okt nov dec

Månad

Tim

ma

r

2008

2009

2010

2011

2012

Videoconference VLL (hours)

32% increase 2008=>2009

36% increase 2009=>2010

27% increase 2010=>2011

Telemedicine – examples

Consultations – Dermathology

– Bacteriology

– Ultrasound (heart and gynecological)

Clinical rounds (local, regional, national) – Radiotheraphy

– Upper gastro

– Hemathology

– Pathology

– Neurology

Treatment / rehabilitation

– Speach pathology

– Hand rehabilitation

Northern care region - examples

– Children with cleft palate

• First meeting with specialist and speech therapis via video

– Newborn with suspected heart disease

• Cardiologist in Umeå diagnoses the ultrasound examination via video

– Rehabilitation after hand surgery • Patient get treatment and rehabilitation in their

home or at the nearest primary care center

16

Telemedicine in rehabilitation Routine since 2009

Hand surgery clinic in Umeå - video sessions with colleagues and patients in the northern region

Telemedicine is used for:

• Clinical consultation to colleagues at health care centres

• Evaluation and control of goal achievement for patients at health care centres

• Distance intervention in the client’s home

18

Technical solution

• Patients own computer and broadband or Ipad with Wifi or 3G

• Cisco Jabber software

• The quality is ”good enough”

Telemedicine in rehabilitation

Distance intervention in the patients home

19

Technical solution

• Videoconference system at the health care centers

•Therapist at the hospital - web cam or videoconferencing system

Telemedicine in rehabilitation

Evaluation and control of goal achievement of patient at health care centres

20

• In 2012 - 238 telemedicine sessions

• 164 journeys to hospital avoided – 82 000 km

• 17 000 euro in reduced travel costs

and

- patients reported the same level of satisfaction

- most patients described less travelling as the greatest benefit

Telemedicine in rehabilitation

Speech and language therapy by video

• To offer patients treatment close to home or in their home

• Equal access to healthcare and rehabilitation

Patient Speech therapist

Speach therapy Routine since 2007

Experience from 2-year project

• 779 telemedicine sessions with 194 patients

• Reduced travel with 154 000 km for patients

• 130 000 euro in reduced travel costs

and

- more alert patients

- less travelling for patients and therapists

- fewer cancellations

- patients completes their treatments – better treatment results!

Chronic obstructive pulmonary disease (COPD)

• Self assessment

• Spirometry measurements

Cognitive disorders • Video consultations

Cardiovascular diseases • Ultrasound robot

Chronical diseases

Goal • detect and prevent serious exacerbations and subsequent hospital admissions • encourage the patient to 'behavior change' - mainly physical activity

Methods: • Sampling of physiological parameters and patient-reported symptoms in the

patients home

• Development of new web-based methods based on theories of health behavior change, motivational interviewing and self-reporting of physical activity

COPD project

Equipment

Video consultations with specialists • Vilhelmina municipality - focus on BPSD problems

• Health care centers in Norsjö, Backen, Malå, Sorsele - focus on diagnostics

for early cognitive impairment

• 3-5 patients present at the monthly consultations

• 1 hour allocated for each consultation

• Web camera based videoconference for the specialist – Cisco Jabber

Specialist support in dementia care

• Limited access to doctors in rural areas

• Limited knowledge in both diagnosis and treatment of both cognitive impairment and BPSD

• Distance consultations saves time and resources for patients and care providers

• Reduced number of referrals and transports over long distances

• Important with locally engaged staff

Experiences from Västerbotten - dementia

[… Movie Ultrasound robot - 2:14 minutes]

Ultrasound robot

Business model – ”work to do”

– Make business models for all running and new telemedicine applications

– Establish models for health economic analyzes

– Find incentives for all parties - patients, primary care centers and hospitals

– Investigate whether a telemedicine visit should cost the same for the patient as a traditional visit

– Establish clear procedures for investment and support costs for technical equipment

Business model - Nothern care region

– University hospital of Umeå provides highly specialized care

(thorax, neurosurgery, neonatel care etc) to all inhabitants in the Northern care region

– The three other countys pays a fixed fee (2,50 EUR/inh/year) to Västerbotten

– The fee includes examination of x-ray images, telephone and telemedicine conultations

(+) Limits the administration

(-) Free use - number of consultations are increasing – resource issue (especially for the radiologists)

Business model - between hospitals in Västerbotten

– Many clinics in Västerbotten are county clinics

• The county clinics are responsible for the budget, the patients

and the resources on all three hospitals… which simplifies the

incentive structure

Business model - between hospitals and primary care

– The travel budget is the key!

• From 2013 the budget for the patient travels are

transferred to the health care centers

• (until today it have been a central budget for the hole

county – a black hole…)

Thanks for your attention!

Thomas Molén, Strategist

Strategic Development Office

County Council of Västerbotten, Sweden

thomas.molen@vll.se

National eHealth collaboration

National eHealth collaboration

CeHis – Centre for eHealth in Sweden

– Create the long-term conditions necessary for developing and introducing nationwide use of IT in health

– www.cehis.se

– The work comprises new citizens' services and support for health and social care provision, a national technical infrastructure and common regulatory frameworks and standards.

– Collaboration between all 21 countys and 290 municipalities

HSA – catalogue of all health workers in Sweden with details of access rights

SITHS – secure access with 2-step control (SITHS cards and PIN-code) based on

HSA

– Used for determining what information health personnel can see from the EHR.

Secure access

NPÖ

NPÖ – National Patient Overview – access to all EHR from all county councils in

Sweden

The patient has the right to limit access to EHR for medical staff

”My health care contacts”

A safe way for the patient to communicate with the health

– Obtain an extract from a patient record

– Obtain medical advice from nurses and psychologists/psychiatrists.

– Change a family doctor

– Make a doctor's appointment

– Change or cancel an appointment

– Renew a prescription

– Renew a certificate of illness

National goals – In 2014; 50 % of the population is using ”My health care contacts” and accessing

this via secure solutions.

– In 2015; 100 % of the population can access parts of their own health record.

– In 2017 they should be able to access all data.

Situation in Västerbotten County Council

5 EHR-systems are used in Sweden, 12 county councils of 21 use the

same in primary care and hospitals

Eletronic health records - national

Eletronic health records - Västerbotten

The County Concil uses one basic system for all units (SYSTeam Cross)

All private health centers working with the county council have to use the same system

Introduction started 1993 and finished 2006; it took us 13 years!

EHR

Radiology

– All images from the county can be viewed anywhere

– All images taken in the four Northern County Councils can be viewed by all radiologists

Biochemistry

– All examinations in one system and can be accessed from the patients record

Costs; computerization

Approximately 2,25% of the County Council`s expenditure is on IT

1.01 employee /PC

Cost/PC 27.000 SEK/year (~300EUR/year)